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Главная » 2007 » Октябрь » 1 » Триада (взгляд врача)

Триада (взгляд врача)

15:36
Кстати, врач на этом обсуждении тоже выступил. Это был д-р Антон Скулверт

Dr. Anton Schoolwerth, he is the Sir Hans A. Krebs Chair of Nephrology at the Virginia Commonwealth University and Vice-Chairman of the Department of Internal Medicine. He serves as the Medical Director of the Clinical Trials Institute of Virginia Commonwealth University and is also the Medical Director of the GAMBRO Downtown Dialysis Center in Richmond. Dr. Schoolwerth received his Doctor of Medicine degree from Harvard Medical School in Boston, Massachusetts, and his Master of Science degree in health administration from Virginia Commonwealth University


Масштабы триады

Поражение сердца, хроническое заболевание сердца, анемия

Антон Скулверт


MD, MSHA




Он говорил о триаде: сердечно-сосудистые заболевания, хронические почечные болезни, анемия. Он привел данные американского регистра почечных больных, свидетельствующие о том, что число почечных пациентов в США продолжает расти и без работы американские нефрологи в ближайшем будущем не останутся.


Как видно из приведенной диаграммы, прогноз роста совпадает с фактическим ростом диализной популяции.
Population of patients with end-stage renal disease (ESRD) is growing
These are the numbers that were generated from the USRDS and extrapolated to the future. In the year 2000 there were over 300,000 Americans on dialysis in the United States, and the projections are that this number will almost double by the year 2010. The is an increasing number of patients coming onto dialysis each year, and the only reason the prevalence, the total number, is not higher, is that we still have a remarkable problem with how poorly our patients do.

Cockcroft DW, Nephron. 1976;16(1):31-41.
Improving on the serum creatinine screening
Now, this is one of several formulas. Sally mentioned the MDRD equation. This is the so-called Cockcroft-Gault equation. We'll find out I think in the next year or two which of these equations becomes the primary recommended one, but at least for those of you who just do things arithmetically with a calculator, this is a little easier to work with. But it estimates the creatinine clearance from the serum creatinine, but adjusting for the patient's age, body weight, and it really should be ideal body weight, and then the gender, male or female. And I have an example here at the bottom just to show you how a marginally elevated serum creatinine or in some cases a serum creatinine that's even with the normal range can be misleading if one does not calculate the creatinine clearance or GFR; an 80 year old woman, 50 kilograms in weight, with a serum creatinine of 1.5 milligrams per deciliter. One would say 1.5 is just a little bit above normal, but if you factor that into this equation, this individual has a creatinine clearance of 24 mLs per minute. This is stage 4 chronic kidney disease. This is advanced kidney disease, but because this individual is elderly and a female, she has less muscle mass to generate the creatinine, and so it's easy to be misled if we just look at the serum creatinine. The same individual with a serum creatinine of 1.2 would still have stage 3 chronic kidney disease.

So, the goal is to have everybody calculate this, and actually the Kidney Foundation has recommended that clinical laboratories begin to report whenever serum creatinine is ordered, report a glomerular filtration rate that corresponds to that much as an INR is reported when someone orders a prothrombin time. And that's going to take a little while but I think that should get peoples' attention.
Мы для этих целей давно уже пользуемся разработанным нами
калькулятором LADY
Когда программа будет загружаться Вы получите предупреждение о возможном наличии в ее составе опасных вирусов или макросов. Будьте уверены, что вирусов там нет а макросы есть. Нажмите кнопку "Да"
 
Интересно, что приблизительно в 1995 году мы анализировали диагнозы пациентов, начинавших ЗПТ в нашей больнице. Оказалось, что приблизительно половина из них пришли к диализу с диагнозом гломерулонефрита (ни у одного пациента не была выполнена биопсия почки). Вот те наши данные 1995 года:


Пациентов с диабетом было 15% (Сейчас их около 30 % в нашем отделении)

Какое разительное несовпадение с данными американцев!
Доктор А. Скулверт приводит следующую диаграмму, отражавшую реальности США в 2000 году:

Просто американы делали биопсию и ставили морфологичекий диагноз, а наши ставили диагноз на основе пресловутого "клинического мышления". Кроме того, конечно, сахарный диабет просто убивает Америку и не видеть его невозможно, а вот у нас его зачастую просто "в упор не видят" - только малая часть диабетиков попадает в поле зрения нефрологов, а должны попадать ВСЕ.
 


Взято из: Meyer KB, Levey AS. Am Soc Nephrol 1998 Dec;9(12 Suppl):S31-42. No abstract available.

Cardiovascular disease
Many of you may have seen this slide; this plots the annual mortality rate from cardiovascular disease as a function of age, starting at the left in the 20s, moving up into the 80s. And we see on the yellow lines that not surprisingly our mortality rate from cardiovascular disease increases as we age. There are slight differences based on gender and race, but we all have a higher risk as we get older. But contrast the general population with the dialysis population which is shown in green, and you see a much flatter line and what's disturbing is that the young dialysis patient, the 30 year old dialysis patient has the same annual mortality rate as a 75 to 80 year old individual from the population at large.
 

Я тут перерисовал картинку д-ра Скулверта. Эта ледянящая душу картина, возможно навеяная д-ру Антону Скулверту просмотром блокбастера "Титаник", на самом деле недалека от истины. Для США, конечно, так как российская действительность выглядит примерно так: на поверхности плавает маленькая льдинка, непригодная даже для размещения пары Мазаевских зайцев, а под водой оказывается глыба в одну седьмую часть суши...

Д-р Скулверт говорил: Still too much emphasis on the tip of the iceberg
It struck many of us in the nephrology community recently that perhaps our emphasis, if we were going to impact on this, should be to look earlier than at the end-stage. Rather than looking at the tip of the iceberg, with the implication that our patients' cardiovascular risk began the day they had their first dialysis, it was likely that this began much earlier, at an early stage, perhaps at the stage when they first developed the risk factors that led to their progressive kidney disease. And so with that kind of background, there has been a great movement that was spearheaded by the National Kidney Foundation to look at chronic kidney disease.
 

Цели лечения хронических заболеваний почек

  • Замедлить наступление тХПН
  • Снизить риск сердечно-сосудистых осложнений
  • Обучение пациентов
  • Улучшение общего качества жизни


Goals of CKD therapy
I'll take a quick aside for those of you who are wondering why we're calling this chronic kidney disease instead of chronic renal failure, chronic renal insufficiency. This was the recommendation that came out of the K/DOQI advisory board, the publication that came out of the ... in the American Journal of Kidney Diseases in February that we use the word 'kidney' rather than 'renal' or 'nephrology'. This is a word that's recognized by the population at large to a much greater extent than renal. At least we can get people thinking about what organ we're dealing with. But the terms of our goals in chronic kidney disease is not only to delay the onset of end-stage renal disease, but really to decrease cardiovascular risk, because that actually has a much greater impact. As I'll show you in a few moments there are many more people who have chronic kidney disease, and are at risk of developing end-stage renal disease. But many of these are going to die of cardiovascular disease even before they reach end-stage disease. So if we can identify these people that's a major plus. To do this will involve empowering and educating patients, and as we collectively approach this, the hope is that we'll improve the overall quality of life of our patients.

Хроническое поражение почек

  • Распространенное состояние
  • Существенная смертность
  • Дорогое лечение
  • Эффективное лечение может замедлить прогрессию
  • Командный подход: врачи первичной помощи и нефорологи


Ссылки: McCarthy JT. Mayo Clin Proc 1999 Mar;74(3):269-73.
Obrador GT, et al. J Am Soc Nephrol 1999 Aug;10(8 ):1793-800.
No Author Listed.

Ann Intern Med 1994 Jul 1;121(1):62-70. No Abstract Available
Chronic kidney disease(CKD)
Now chronic kidney disease is common. I'll show you some data on that in a moment. It has significant morbidity. The treatment is expensive and it's particularly expensive if the patients are not identified and treated early. And what's particularly important is that we now have effective treatments that can slow the progression of disease, and can reduce cardiovascular morbidity. But to do that entails a team approach. And you're going to hear this evening how at least at one institution we've tried to address this using a team of effort to help our patients.
 

Распространенность разных стадий хронического поражения почек во взрослой популяции американцев (старше 20 лет)

Стадия

Степень снижения СКФ

СКФ

Число (тыс.чел.)

% в популяции

0

Повышен риск

более 90 с факторами риска

?

?

1

Повреждение почек с нормальной или повышенной СКФ

более или равно 90

10500-5900

5,9-3,3

2

Повреждение почек с незначительным снижением СКФ

60-89

7100-5300

4,0-3,0

3

Умеренное снижение СКФ

30-59

7600

4,3

4

Тяжелое снижение СКФ

15-29

400

0,2

5

Почечная недостаточность

менее 15 (или на диализе)

300

0,2



Stages and prevalence of CKD
Now this is a similar slide to what Sally showed you a few moments ago, and this is I think a very important slide because it comes from the CKD guidelines from the K/DOQI advisory group, and what I want to start with is over on the right and then I'll come back to the left part of the slide. Based on some epidemiological data that have been collected through the so-called NHANES study on a periodic basis, we have information on the number of individuals who have chronic kidney disease. There are a lot of different numbers here and it's based a little bit on how the screenings were done. But it involved a cross-section of the population who had among other things, creatinines measured and protein measured in their urine. If one urine was tested and used as the sampling, it led to a higher prevalence. But the point here is these numbers are in thousands. And in contrast to 300,000 Americans on dialysis, we're talking about millions of Americans who have chronic kidney disease.

And to summarize this figure, the National Kidney Foundation estimates that there are 20 million Americans who have chronic kidney disease, most of whom do not know they have it, and another 20 million who are at risk.

Now in order to develop a more systematic approach to not only identifying but then treating these patients, the NKF has recommended that we stage these patients based on their glomerular filtration rate. And if we use a value above 90 as normal, people can still have chronic kidney disease, if they have evidence of damage to the kidney, such as protein in the urine, albuminuria, proteinuria, and that would be at stage one. But as the glomerular filtration rate decreases, as the disease progresses, the stage increases and they have proposed five stages down to level five, which is when the glomerular filtration rate is below 15 mLs per minute. And that's the level at which patients are very close to if not already needing dialysis. So the goal is to reduce the number of people that reach stage five by finding them, by identifying their disease at an earlier stage where we might have a good way to impact their progression as well as their cardiovascular risk.
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